2014 Reimbursement Update Impact on education and clinical practice  for communication Sciences and Disorders- Part twoRobert C. Fifer, Ph.D.Mailman Center for Child Development, University of Miami

Disclosures

Program evaluator for Duke University Medical School and University of Texas Medical Branch

Presenter at New Mexico Speech and Hearing Association, North Carolina Academy of Hearing Rehabilitation

Member Genetics and Newborn Screening Advisory Council, Florida Department of Health

Consultant to Children’s Medical Services Audiology Review Committee

Member ASHA’s Health Care Economics Committee

Documentation Requirements

1997 Documentation Guide for E/M Coding• History (Soap):

– Medical necessity for why the patient is there• “Referred by” is not medical necessity• Requires a history covering the following areas

as appropriate– Chief Complaint– Duration of symptoms– Family history– Social / occupational history– Prior medical history– Relevant diagnoses

– This section justifies all that is done

Documentation Requirements

Actions and results (sOap)Describing what was done

The test forms cannot stand on their ownMost professionals don’t know what it is or

what the raw results meanDescription of procedures and observations

Procedure description can be “canned”Description of what was found (results)

Documentation Requirements

– Clinical Assessment (soAp)• Must have a clear statement of practical and

clinical significance• Must flow logically from the history and the

findings

– Recommendations (soaP)• Logical conclusion to the matter.• Based on these outcomes, the following

recommendations are offered:…………• Each recommendation must be supported by

history, findings, and interpretation• Do not list unsupported recommendation

Additional Notes on Recommendations

Medical NecessityAll recommendations must be supported by the

concept of “medical necessity”Recommendation should not be offered that is

for the convenience of health care provider or patient

Transfer to plan of careUse of reportSeparate document (Recommended)

Other Requirements

• Signature– If a paper report, must be an original signature– Facsimile or stamped signature is not appropriate– If electronic medical record (EMR), your login

constitutes your signature

• Date– Date of service must be specified and prominent

in report– Other dates may include date of review, date of

“signing”, date of dictation. These must be distinguished from date of service.

Impact of ICD-10 on Documentation

ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added

Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected

Will affect descriptions of what was found and clinical assessment statement.

BE CLEAR IN WHAT YOU WRITE!

9

Say What You Mean – Clearly!

I saw your patient today, who is still under our car for physical therapy

The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week."

Patient has chest pain if she lies on her left side for over a year.

Discharge status: Alive but without permission. Patient needs disposition; therefore we will get Dr. Blank to dispose of him

10

Say What You Mean – Clearly!

The patient was to have a bowel resection. However, he took a job as stockbroker instead.

The patient is tearful and crying constantly. She also appears to be depressed.

The patient refused an autopsy.

The respiration tube was disconnected and the patient quickly expired.

Personal Observations

Consists of audiogram with some notesEx: Referred by Dr. Razzelfratz for hearing

test. Recommend hearing aids

Fails to meet federal guidelines for minimum documentation standards for covered services

Therapy notes incomplete or has sign-in sheets only

Diagnosis Coding

October 1, 2014

To International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM

ICD-9-CM: Approximately 18,000 codes

ICD-10-CM: Approximately 64,000 codesProvides more flexibility for adding new codes

12

Clinical BillingCoding “Normal”

DiagnosisMedicare guidelines on code selection

Not allowed to be “normal” within the ICD-9 or ICD-10 coding system

Code signs / symptoms that caused you to do the test

Some recommend use of a V code for test encounter following (for example “Examination following a failed screening”

ICD-10-CMH90 Conductive and Sensorineural Hearing Loss

Includes: Congenital deafness

Excludes: Deaf mutism NEC (H91.3)Deafness NOS (H91.9)Hearing loss NOS (H91.9)Noise-induced (H83.3) Ototoxic (H91.0) Sudden (idiopathic) (H91.2)

14

ICD-10-CMH90.0 Conductive hearing loss, bilateral

H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side

H90.2 Conductive hearing loss, unspecified Conductive deafness NOS

H90.3 Sensorineural hearing loss, bilateral

H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side

15

ICD-10-CM

H90.5 Sensorineural hearing loss, unspecifiedCongenital deafness NOSHearing loss:

central } NOSneural } NOSperceptive } NOS sensory } NOS

Sensorineural deafness NOS

16

17

Emphasis on Outcomes

Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system.

Now requires CMS to collect functional status and outcomes measurements

Seven-level functional outcome system to be phased in this year for therapy services

Similar to NOMS in structure

Changing Landscape

International Classification of Functioning, Disability and Health (ICF)

Describes body functions, body structures, activities, and participation

Useful for understanding and measuring outcomes

ASHA has information available online

18

ICF Levels

19

0 No impairment means the person has no problem

1Mild impairment means a problem is present less than 25% of the time, with an intensity a person can tolerate, and happened rarely over the last 30 days.

2Moderate impairment means a problem is present less than 50% of the time, with an intensity that is interfering in the person’s day-to-day life, and happened occasionally over the last 30 days.

3Severe impairment means a problem is present more than 50% of the time, with an intensity that is partially disrupting the person’s day-to-day life, and happened frequently over the last 30 days.

4Complete impairment means a problem is present more than 95% of the time, with an intensity that is totally disrupting the person’s day-to-day life, and happened every day over the last 30 days.

8 Not specified means there is insufficient information to specify the severity of the impairment.

ICF Levels

20

21

Documentation and Audits

Greatest problem in audits

Often inadequate and over-simplified

Often not clear

Mismatch between CPT and diagnosis codes unsupported by documentation

Audits

To protect the Medicare Trust Fund Medicare QIO (Quality Improvement

Organization) CERT (Comprehensive Error Rate Test) RAC (Recovery Audit Contractor) ZPIC (Zone Program Integrity Contractor) MAC (Medicare Administrative Contractor) PSC (Program Safeguard Contractor) OIG (Office of Inspector General Audits)

Audits

To protect Medicaid funds MIP (Medicaid Integrity Program) MFCU (Medicaid Fraud Control Unit) RAC (Recover Audit Contractor) IMRO (Independent Medical Review

Organization

“In Your Presence” Audits

QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients

MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness

MIC reviews: Looking for overpayments and billing errors

MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes)

“Behind the Scenes” Audits

ZPIC oversees the RACs and approves their CPT code selection for data-mined audits

RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting

PSC obtains information from RACs regarding possible fraud and abuse

Recovery Achievements

RAC Pilot Project 3 year demonstration 6 states $1.3 billion recovered in overpayments

Overpayments Medicare: $49.9 billion in 2013 Medicaid: $14.4 billion in 2013

Point of comparison Deficit reduction bill by Rep. Ryan cut $20 from

budget

Attributes of Overpayments

Administrative and documentation errors

Medically unnecessary services

Diagnosis coding errors

Inappropriate procedure code reporting

Prevention of Bad Outcomes

KNOW THE RULES!!!!! Correct coding

Types of codes Don’t go “code fishing” Be truthful in code selection

Documentation “If it wasn’t documented, it never happened” The audiogram cannot stand alone, not even with

notes Six elements of documentation – EVERY TIME

Medical necessity – justify ALL procedures

Clinical BillingCode Selection

With rare exception, do not go outside of our family of codes for SLP and Aud services

Do not code shop for what sounds good without understanding the procedure represented by that code

If a procedure does not have a code, use the unspecified/unlisted code 92700

Know the difference between a unit code, contact code, and timed code

Clinical BillingCode Type

Contact code Untimed code reported once per date of service Will have no unit or timed designation in the descriptor

Unit code Report the code up to a maximum number of times per

date of service Designated by maximum number of units in descriptor

Timed code Designated in descriptor by “1st hour” or “each

successive 15 minutes”

Clinical BillingTimed Codes

Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true

Be conservative when reporting the portion of time devoted to report writing

Document in progress notes the start time and stop time for the face to face contact

Clinical BillingSupervision

Medicare requires 100%, in the room supervision Medicare pays for the licensed professional’s time

and not the student’s effort Decision-making must be by the professional Cannot be involved with care of a second patient

Medicaid Supervision may vary from state to state Typically professional contact with family and

student to ensure appropriate procedures, outcomes, and decision-making

Depending on the student, may not require 100% supervision

The Question of Whether to See

Medicare PatientsDepends on supervision level and medical necessity

Practice patients / clients

If supervision CAN be met and the decision is to see Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily)

If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations

Per Capita Spending for Health Care; Source: Kaiser Family Foundation

34

38 years of per capita spending by country

Health Care Costs for American FamiliesSource: Milliman Medical Index

35

Health Care Costs for American FamiliesSource: Milliman Medical Index

Health Care Costs for American FamiliesSource: Milliman Medical Index

Miami most expensive at $24,965.00

Phoenix least expensive at $18,365.00

Primary utilization factors influencing out of pocket and overall expenses: Inpatient facility care Outpatient facility care Professional services Pharmacy Other

Health Care Economics

Cost inflationRisen 78% since 2000 vs. 20% for salariesAverage 9% per year with range of 7%-13%Defensive medicine (malpractice)Unnecessary procedure/treatment (fee for

service)Ineffective treatmentInefficient service delivery modelsPharmaceuticalsEnd of life care

Factors Affecting Reimbursement

Sustainable Growth Rate (SGR)

PQRS

New models of reimbursement

Procedure reviews

New Challenges

Sustainable Growth Rate

Part of the 1997 Balanced Budget Amendment to keep Medicare budget neutral

Includes several factors to calculate the reimbursement of Medicare services

Independent from RVU assignments from AMA

Annual budget allocation from Congress

Sustainable Growth Rate

Intended to control the growth of Medicare costs

Payments for services not withheld if SGR targets are exceeded

If target expenditures exceed budget, the next year’s update is reduced

If target expenditures are below budget, the next year’s update is increased

Sustainable Growth Rate: How does it work?

The estimated percentage change in fees for physicians’ services.

 The estimated percentage change in the average number of Medicare fee-for-service beneficiaries.

The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. (from 2008 forward)

The estimated percentage change in expenditures due to changes in law or regulations.

Year % decrease

Year % decrease

Year % decrease

1996 -0.3 2004 6.6

1997 3.2 2005 4.2

1990 9.1 1998 4.2 2006 1.5

1991 7.3 1999 6.9 2007 3.5

1992 10.0 2000 7.3 2008 4.5

1993 10.0 2001 4.5 2009 6.4

1994 7.5 2002 8.3 2010 8.9

1995 1.8 2003 7.3 2011 4.7

SGR Adjustments: 1990-2011

The “Doc Fix”: Introduced February

2014 Immediate repeal of SGRTransition period with 0.5% increase annually for 5

yearsMerit Based Incentive Program

PQRS Value Based Modifier Meaningful Use for Electronic Medical Records

5% added incentive payment to physician payment under new Alternative Payment Models

Increased funding for technical assistance to small physician practices (<15 physicians)

Creation of a technical advisory panel to review and recommend Alternative Payment Models

Noteworthy Features of “The Fix”

Consolidates quality programs (e.g., PQRS, Value Based Modifier, Meaningful Use) into one.

Payments based on achieving performance thresholds

Introduces the concept of alternative payment models

Incentivizes care coordination and shared responsibility of patient care

Requires ongoing development of quality measures to evaluate performance

Other Noteworthy Features of “The Fix”

Increases transparency of metrics and quality Physician Compare website Posts quality and utilization data for patients to

make informed decisions about their care Allows qualified clinical data registries to

purchase claims data for purposes of quality improvement and patient safety

Latest News on Doc Fix 3/31/14

Congress passed a bill to delay to freeze the current situation for one year.

Suspend 24% reduction in payments

Extend the therapy caps exceptions until March 2015

Delay implementation of ICD-10 for one year

Other Factors Affecting Reimbursement

CMS Screens of billed codes looking for Codes frequently reported together Codes that have never been surveyed by the

RUC or HCPAC Codes believed to be overvalued based on

utilization increases

AMA Responses to CMS Overseeing survey process Facilitating potential methods of payment

revision

Physician Quality Reporting Initiative

(PQRS)One of three performance based

reimbursement factors affecting physicians – the primary performance based factor for audiologists at present

Began as an enticement to physicians to abide quality of care standards

Participation is now a requirement to maintain full Medicare reimbursement

Each health care discipline / specialty will develop performance standards

51

PQRS

Quality measures as evaluated by National Quality Alliance, Physician Consortium for Performance Improvement, and CMS

Has moved to mandatory participationPenalty Adjustment: -1.5% in 2015; -2% in 2016

and beyond

Most recent rule for 2014 requires reporting on 9 measures. Audiology and speech-language pathology exempted from that for now.

PQRS MeasuresAudiology

Document or confirm the patient's current medications for 50% of the eligible patient visits for evaluation AND

Indicate a referral to a physician for 50% of the patients who report or are diagnosed with dizziness

PQRS MeasuresSpeech-language

PathologyDocument or confirm the patient's

current medications for 50% of the eligible patient visits for therapy

PQRS Measures

PQRS applies to audiologists and SLPs in private practice, group practice, or university clinics.

At this time, PQRS does not apply to providers in facilities such as hospitals or skilled nursing facilities.

Separate enrollment is not required.

55

Additional PQRS Item:

Under SGR repeal, each “society” will develop discipline-specific measures

Audiology is represented in this effort by the Audiology Quality Consortium (AQC)

AQC is comprised of representatives of 10 audiology organizations (list on ASHA, AAA, and ADA websites)

At this moment, there are 5 proposed measures in development

56

Health Care economics: Do I turn right or left to

get to the future?

Current Recommendation

MedPAC: Move Away From Fee-for-ServiceEncourages increased utilizationMore services => more paymentQuestions of true medical necessity

IOM and CMS: Move Away From Fee-for-Service

57

Medicare/CMS Actions

Value-Based PurchasingBased on Medicare vision of “the right care for every

person, every time”Aligns payment to efficiency and quality of care

deliveryRewards providers for measured performance (read:

outcomes)

58

Value-Based Purchasing

Promote evidence-based medicine

Require clinical and financial accountability across all settings

Focus on episodes of care

Better coordination of care

Payment based on outcomes, not number of sessions (performance-based payment)

Focus on effectiveness of treatment59

60

Levels of Evidence

Level Type of evidence (based on AHCPR 1992)Ia Evidence obtained from meta-analysis of randomized controlled trialIb Evidence obtained from at least one randomized controlled trialIIa Evidence obtained from at least one well-designed controlled study

without randomizationIIb Evidence obtained from at least one other type of well-designed

quasi-experimental studyIII Evidence obtained from well-designed non-experimental descriptive

studies, such as comparative studies, correlation studies and case

control studiesIV Evidence obtained from case reports or case seriesV Evidence obtained from expert committee reports or opinions and/or

clinical experience of respected authorities

Bundled Payments

Bundled payment models de-emphasize services that increase utilization and cost

Initiative by Center for Medicare and Medicaid Innovation called Bundled Payments for Care Improvement

Working to identify procedure groups to bundle, based on diagnosis rather than procedure(s)

61

Current CMS Actions to Reduce Payments

Medicare screens for procedures reported together => new, combined procedure CPT codes (92540, 92550, 92570)

Re-survey and re-validation of procedure value (92587)

Bundled payments under Medicaid reform (more on this later)

62

Medical Home Model

Primary care physician becomes medical manager

All referrals will go through PCPDifferent from “gate-keeper” concept of HMOsPCP paid to coordinate and manage all care of that

patientWith rare exception, no physician/health care provider

will have “direct access” under medical home model

63

Physician Private Practice Diminishing

Physicians are facing same pressures as hospitals

Leaving private practice to become salaried employees of hospitals and other large medical organizations Lower costs Meet government mandates on electronic medical

records Percentage of physicians who own their own

practices 2000 – 57% 2009 – 43% 2013 – 33% (projected)

Physicians and Private Practice

Giving up fee for service or a salary… Physicians lose autonomy Gain more regular hours Gain more predictable income level Hospitals gain a guaranteed supply of patients

from the physicians practices

Intent of health care changes under Obama More coordinated care (shared patient

management) Leading to cost reductions and better patient

outcomes Eliminate “silo” style of operation for patient care

66

Emphasis on Outcomes

Patient Satisfaction and Wellness

Patient Centered (What do you want me to do?)

FQHC payment per encounter Average payment Diagnosis based

Influence by Medical Home

Shared responsibility for care (Again, emphasis on Care Coordination and elimination of silos)

Emphasis on Patient Centered Care

Remove traditional prescriptive perspective from SLPs and Auds

Patient / family actively participate in decision-making

Patient / family establish goals to be achieved

SLP / Aud role to educate, evaluate, guide, empower

Standard Versus Custom Protocols

Every procedure must be supported by history or other test findings

Every protocol must be customized for each patient based on the clinical question to be answered

What we currently know of reimbursement directions indicate that it will be necessary to do what is necessary and stop there

Bottom line: the individualized clinical question will be the driving force for what is done diagnostically

Effects on Audiology

We are not physicians, but sometimes the system treats us like physicians for payment and policy

We don’t know what our reimbursement will look like, but we have some hints based on physician-center proposals and movements away from fee-for-service

Pay attention to the diminishing physician private practice and move toward joining large health care organizations

Effects on Audiology

Changes in health care will require that you determine cost of service delivery

Carefully evaluate each procedure being performed (e.g., develop a clinical question and determine what tools are necessary; stay away from graduate school protocol …Time is money and each additional procedure is

timeJustify what you do based on case history and

outcome of previous test

70

Effects on Audiology

Anticipation that payment may be based on diagnosis or “per patient” rather than procedureReplace fee-for-service with bundled code

crosswalked to diagnosisBundled fee based on data-mining median costs of

procedures “typically done” to derive diagnosisMay combine severity with diagnosis via ICF or similar

scaleFocus on participation in life activities (NOT ADLs—life

activities)

71

Effects on Speech-Language Pathology

Anticipate episodic / periodic payments Single payment Covers all services Covers specified period of time Already appearing in Medicaid “reform”

Single payment for date of service

Based on diagnosis and level of severity

Focus on FUNCTIONAL outcomes Realistic achievement of goals Activities of life

Reimbursement Summit

Factors Pressuring ChangeUnsustainable increasing cost of medical care

Patient Protection and Accountable Care Act

Increasing demands for quality, efficiency, and accountability by Regulators Health Care Rating Organizations Accrediting bodies Employers Commercial payers The Public

Triple Aim Focus of ChangeInstitute for Health Care

Improvement

Improving the patient experience of care (including quality and satisfaction)

Improving the health of populations

Reducing the per capita cost of health care

Impact on Graduate School Training

Teach clinical judgment rather than strictly procedures and protocol

Mechanics of test administration are important, but know when to stop (emphasis: Aud)

Mechanics of test administration and therapy techniques are important, but know how to set realistic goals (emphasis: SLP)

Develop a true sense of medical necessity, clinical questions, patient-centered recommendations and plan of care

Value of Health Care

“We practice according to how we are paid”

Peter Hollmann, MDChair, AMA CPT Editorial PanelOctober 2011